TABLE OF CONTENTS

INTRODUCTION

SPECIAL PLAN PROVISIONS UNDER THE SHBP

Women’s Health and Cancer Rights Act

Automobile-Related Injuries

Work-Related Injury or Disease

Health Insurance Portability and Accountability Act

Mental Health Parity Act Requirements

Certification of Coverage

HIPAA Privacy

Purchase of Individual Insurance Coverage

Medical Plan Extension of Benefits

Audit of Dependent Coverage

STATE HEALTH BENEFITS PROGRAM ELIGIBILITY

Active Employee Eligibility

State Employees

Local Employees

Eligible Dependents

Medicare Coverage While Employed

Retiree Eligibility

Aggregate of Service Credit

Eligible Dependents of Retirees

Enrolling in the Retired Group of the SHBP

Medicare Coverage

How to File a Claim If You Are Medicare Eligible

Retirees With Medicare Who Move Outside the United States

COBRA COVERAGE

Continuing Coverage When It Would Normally End

COBRA Events

Cost of COBRA Coverage

Duration of COBRA Coverage

Employer Responsibilities Under COBRA

Employee Responsibilities Under COBRA

Failure to Elect COBRA Coverage

Termination of COBRA Coverage

TRADITIONAL PLAN BENEFITS

Using This Handbook

How to Determine Available Benefits

GENERAL CONDITIONS OF THE PLAN

Medical Need and Appropriate Level of Care

Reasonable and Customary Allowances

Experimental or Investigational Treatments

Educational or Developmental Services or Supplies, or Educational Testing

Predetermination of Benefits

Custodial, Maintenance, and Supportive Care

Discounted Providers

Prescription Drug Benefits

Employee Prescription Drug Plan

      Plan Benefits

Prescription Drug Benefits Provided Through SHBP Health Plans

Employee Prescription Drug Reimbursement Plan for Traditional Plan Members

Retiree Prescription Drug Coverage

Coordination of Benefits

BASIC BENEFITS

Hospitalization

Coverage in the Hospital

Alcohol and Substance Abuse Benefits - Inpatient

Eligible Services and Supplies

Other Services Paid Under Basic Benefits

Birthing Centers

Dental Benefits - Inpatient

Dialysis

Federal Government Hospitals

Home Health Care Agency Benefits

Home Hemophilia Treatment

Hospice Care Benefits

Mastectomy

Mental Health Benefits - Inpatient

Obstetrical Care Benefits - Inpatient

Organ Transplants

Pre-admission Testing

Private Rooms

Skilled Nursing Facility

Surgical Centers/Ophthalmic Surgical Centers

EXTENDED BASIC BENEFITS

Eligible Services and Supplies

Service Benefits

MAJOR MEDICAL BENEFITS

Services and Supplies

Major Medical Payments

Deductibles

Coinsurance

Lifetime Benefit Maximums

Major Medical Maximums

Mental Health Maximums

Automobile-Related Injuries

Specific Coverage Areas

Acupuncture

Alcohol and Substance Abuse Treatment

Allergy Testing

Ambulance

Biofeedback

Blood

Breast Reconstruction

Chiropractic Services

Congenital Defects

Dental Care

Diabetic Self-Management Education

Hospital-Based Weight Loss Programs

Infertility Treatment

Lithotripsy Centers

Lyme Disease Intravenous Antibiotic Therapy

Mammography Benefit

Mental Health Treatment

Orthopedic Shoes

Pain Management

Pap Smears

Patient Controlled Analgesia (PCA)

Physical Therapy

Private Duty Nursing

Scalp Hair Prostheses

Second Surgical Opinion

Shock Therapy Benefits

Speech Therapy Benefits

Surgical Services

Temporomandibular Joint Disorder (TMJ) and Mouth Conditions

Voluntary Case Management

CHARGES NOT COVERED BY THE PLAN

Third Party Liability

Repayment Agreement

Recovery Right

When You Have a Claim

Filing a Claim

Filing Deadlines - Proof of Loss

Itemized Bills are Necessary

Foreign Claims

Filling Out the Claim Form

Submitting a Claim

Hospital Claims

Medical Claims

Medicare Claims and Other Coverage

Out-of-State Claims

Authorization to Pay Provider

Questions About Claims

APPENDIX I — Summary Schedule of Services and Supplies

Basic (Hospitalization) Benefits

      Covered Services

Extended Basic (Medical-Surgical) Benefits

      Covered Services

Major Medical Benefits

APPENDIX II — Claim Appeal Procedures

Appendix III — SHBP Medical Treatment Policies

Infertility Treatment

      Eligible Services

      Ineligible Services

Lyme Disease Intravenous Antibiotic Therapy

      Diagnosis

      Early Localized Lyme Disease

      Early Disseminated Lyme Disease

      Late/Chronic Disease Lyme Arthritis and Late/Chronic Disease Neuroborreliosis

APPENDIX IV — Glossary

APPENDIX V — SHBP Notice of Privacy Practices

State Health Benefits Program Contact Information

State Health Benefits Program Publications

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